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HomeMy WebLinkAbout0136 CEDAR STREET �i . 7 �I l' a O. 152 1i3 C?RA TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Jv Parcel Application#60 Health Division Conservation Division Permit# Tax Collector Date Issued 10 Treasurer Application Fee Planning Dept. Permit Fee •- .�, �a Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis /7 1/0-1 Project Street Address 156 Cej� Sf Village a;�r h `e- Owner u.s S e 1 �T0 6 S 0 h Address 3 CeJO-u_. �. Telephone ( 5 OS')___3 16 l 3 f� 3�b Permit Request ( A,A le r&—toadk e o Iry . 0 Qfinn "A �+/ .a_�- f � i IA. 2 a a\6 v 0,,VAA 011iA w 3 w Q If 00 Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation '4 1 5 0 o °a Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentatiR { Z Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) to Ci) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Hig ay: ❑ts No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other + Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing. new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing 0 new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑ No If yes,site plan review# Gurre4'Use Proposed Use - BUILDER INFORMATION Name ��-`'�SS �eA L O �\vvs a V-, Telephone Number C, o Address �C License# )14 !M 6 l i 6L Home Improvement Contractor# Worker's Compensation# I I I ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO L V\ F✓ 1' SIGNATURE DATE FOR OFFICIAL USE ONLY 1 . PERMIT NO. i DATE ISSUED r MAP/PARCEL NO. _ ADDRESS VILLAGE, ' i OWNER ' , i r DATE OF INSPECTION: kr FOUNDATION i FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL I FINAL BUILDING 8F —6A *&C— ' DATE CLOSED OUT a� ASSOCIATION PLAN NO _ i , f i k - The Commonwealth of Massachusetts A Department of Industrial Accidents Office of Investigations li4 ° 1 600 Washington Street Boston,MA 02111 t www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Irfdividual): (,-TQ k h s a s Address: cc_ City/State/Zip: W,l &ft S �e; 0 �`Phone#: 15 a f — ?> 6 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- , listed on the attached sheet. t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. workers' comp.insurance. Y P tY• 9. ❑Building addition o workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3. I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions . myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Si ature: /' \ Date: IV 1) Phone#: ( �J O� ) 36 oz— 3 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ' Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual;partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence.of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#i 617-727-77-49 . Revised 5-26-05 w.mass.gov/dia oF'It HE, Town of Barnstable Regulatory Services % snniv•�►sssrAZ�. ' Thomas F.Geiler,Director y � �p�fp : a Building Division Tom.Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstabl e.ma.us Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units.or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along vsdth other requirements. e of Work: "c—S e a J' o�` �Nssmated Cost J5©V Type � Address of Work. 13 (o Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law ❑Job Under$1,000 ❑ ilding not owner-occupied Azowner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Signature Registration No. OR Date Owner's Signature Q:wpoes.forms:homeaffi day Rev: 060606 / •r , Town of Barnstable �OFTHE Tp�� • o� Regulatory Services ! Thomas F.Geiler,Director • saaNSTaar.E Mass. 9q, s639. `0� Building Division gED MP't s Tom Perry,Building.Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: � e JOB LOCATION: l 3 6 C nuumber street ? vi "HOMEOWNER": ��1/�s o v, 66 ri > 6 3 7-Villlage name home phonee## work phone# ( CURRENT MAMWG ADDRESS: L �3 b bc vw%Sc{�t city/town state zip code .The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as . supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one of two-family-dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to-the Building Official on a form acceptable to the Building'Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Ho er Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section.127.0 Construction Control. . HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such .. work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. a Q:fonns:homeexernpt J . Application to ®pb Ring'# 3�tgflbjap XRegiDnal his torir �W.Vtritt Committee in the Town of Barnstable CERTIFICATE OF APPROPRIATENESS Application is hereby made,with four complete sets,for the issuance of a Certificate of Appropriateness under Section. 6 of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on Plans,= drawings, or photographs accompanying this application for. c> CHECK CATEGORIES THAT APPLY: 1. Exterior building construction: ❑ New ❑ Addition Aiteration Indicate type of build' g: House Garage ❑ Commercial ❑ Other 2. Exterior Painting: 9 3. Signs or Billboards: ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign 4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑Other r TYPE OR PRINT LEGIBLY: DATE 13 6 ADDRESS OF PROPOSED WORK ASSESSOR'S MAP NO. /3 c' OWNER 1�4 �y �S�o ASSESSOR'S LOT NO. r HOME ADDRESS Qa>< a (1�eST��� M D S (p TELEPHONE NO. FULL NAMES AND ADDRESSES OF ABUTTING OWNERS, including those of adjacent property owners across any public street or way. (Attach additional sheet if necessary.) \ �, r. + 0. Ah lh lma'c�-&V AGENT OR CONTRACTOR TELEPHONE NO. ADDRESS DESCRIPTION OF PROPOSED WORK: Give particulars of work tp be done, including materials to be used. Please include locations of proposed signs. \\ i. ( a e ��wt St'dewwil � SknI'q 40 CIGLf6`oarAS (C010r �;,�r�ttijre� ' CiJ 'P5cje 3� (9v�,� Goro. � TO�v� C Cod or c�atvlwl= apo 6a Signed er-Contractor-Agent For Committee Use Only OVI e / pp This Certificate is hereby y EDI ate o L v A d/Denied OCT ,0 6 1005 Co embers' Signatures TOWN OF BARNSTABLE It HISTORIC PRESERVATION Town of Barnstable • Old King's Highway Historic District Committee SPEC SHEET FOUNDATIO I 1 1 (1 1 /1 �S f Jle SIDING TYPE �1 k y��`�'��,VO����IM COLOR �_r , 7' l y se CHIMEY TYPE COLOR ROOF MATERIAL d COLORa � � PITCIi WINDOWS COLOR SIZE TRIM COLOR DOORS COLORS SHUTTERS - COLORS CL- GUTTERS COLORS DECKS MATERIALS `3 j \([�/ (,�,b��fdtc.�SS' �sOrS •�,�Ci OJ� -7 `(�r-i urn GARAGE DOORS Cu��v' 4 G�,e,`D"`r COLORS Uv r 1z SKYLIGHTS SIZE r COLORS M E SIGNS COLORS D OCT . 6 ?�l(15 TOWN OF BARNSTAM PENCE COLOR HISTORIC PRESERVATION NOTES: Fill out completely, including measurements and materials/colors to be used. Four copies of this form are required for submittal of an application, along with Four copies of the Plot plan, landscape plan and elevation plans, wham applicable. i l 1 I i y � i I i 40 `I vc 3 s OCT -0 6 2005 �pC d E � �\ d r v d o 3 TpWN OF BARNSTABLE y> - HISTORIC PRESERVATION r t d o � u— U 0 �Q a, 0 O � oho 3 1� : . The Town of Barristabl • .�sHsrnsts • Department of Health Safety and Environmental Services �� • Building Division 367 Main Street,Hyannis MA 02601 Ralph Crossen Office: 508.790-6227 Fax: 508-790-6230 Building Commission. -For office use only •Permit no. Date— AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION• , MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization. conversion,;improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. �} :/Type of Work: l Est. Cost �C Address of Work: 3 W LXZOwner's Name _,,'�ate of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. ORaf � 4 c/ Date Owe s Nam The Commonwealth of Massachusetts __: Department of Industrial Accidents �- 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit XX �ame: locatio . hone# :Ia�m a homeowner performing all work myself. ❑ I am a sole ro rietor and have no one workin in any capacity ❑ I am an employer providing workers' compensation for my employees working on this job. „ mpanv name address... city- ... insurance co. Rolicv#:: ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name eddres3. - :.:. ... city sohone#.. . . • insurnnce co., c.: address: CItV' nh:;;xa. ..... ..... ::...:: - .,. insurance Failure to secure coverage a,required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to 51,500.00 and/or one yearn'imprisonment as well as dvfi penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify un he pains and penalties of perjury that the information provided above is true correct. Signature— / Date _ . Print name Phone# official use only do not write in this area to be completed by city or town official city or town: permtt/license# ❑Building Department ❑Licensing Board ❑checkif immediate response is required + ❑Selectmen's Otflce ❑Health Department contact person: phone#; ❑Other (raised 9/95 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their. employees. As quoted from the "law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewai of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned fe the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. , The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Imlesugatlons 600 Washington Street Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION P1,6ase print. DATE /JOB. / .. .... LOCATION 3 Number Street address Section of town 'HOMEOWNER" e Home phone Work phone PRESENT MAILING ADDRESS City town State Zip code The current exemption for "homeowners" was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person (sy who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"- shall submit to the Building Officia_ on a form acceptable to the Building Official, that he/she shall be res onsiblE: for all such work performed under the building permit. (Section 109. 1. 1) The undersigned "homeowner" assumes . responsibility for compliance with the Stat Building Code -and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Depar nt minimum inspection procedures and requirements and that he/she will com y with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICI VL Note: Three family dwellings 35, 000 cubic feet, or -larger, will be required to comply with State Building Code Section 127. 0, Construction Control. HOME OWNER' S EXEMPTION The code state that: "Any Home Owner performing work for which a building permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that if Home Owner engages a person (s) for hire to do such work, that such Home Owne: shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for licensing Construction Supervisors, Section 2. 15) .. This lack of awareneE often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home ' Owner-' actin as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/Ater responsibilities, man communities require, as part of the permit application, that the Home Owner certify that he/she understands the responsibilities of a supervisor. On the last page of this issue is a form currently used by several towns. You may care. to amend and adopt such a form/certification for use in your community. SIDEWALLING f located in OKH or Hyannis Historic District-Certificate of Appropriateness required unless same color/same materials specified on application. Sign-offs from: Health Tax Collectors' Office r/T ' Owner's name&address Estimated Cost Complete dwelling Information for the Assessor's dept. Correct square footage OR number of squares of shingles(times 100 sq.ft.) Applicant's telephone number Signature Workman's Comp. form Home Improvement Contractor Affidavit ;,,,�Home Improvement Specialist's License OR Homeowner's License Exemption /Fee q-forms-PERMITS I Rev 2/10/98 44L ; Lngineering Dept.(3rd floor) Map 3 y Parcel On 2 Permit# ,�$ ® House# /3 /J Date Issued Board of Health 3rd floor (8:15 -9:30/1:00- )6;f ee y O Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Planning Dept.(1st floor/School Admin. Bldg.) SEPTIC SV �rt►�►p Defi 'tive Plan Approved by Planning Board 19 B1VS-rALLED 9N A TOWN OF BARNSTAYN B � °'� �'�L / Building Permit Application Project Street Address Village v Owner Address Sa..CZ -e Telephone — Permit Request First,,Floor square feet Second Floor square feet Construction Type Estihlated Project Cost $ 060 Zoning District Rr-- Flood Plain Water Protection Lot Size ��- at1T11P1- Grandfathered Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 5D Historic House Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: j Full Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) (� Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: Existing 3 New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas • XOil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing d New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning of Appeals Authorization ❑ peal# Recorded El Commercial ❑Yes No If yes, site plan rev # Current Use Prop d Use Builder Information Name 0— Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �� UILDING PER DEN ED FOR THE OLLOWING REASON(S) r i FOR OFFICIAL USE ONLY 46. i = PERMIT NO. 9 DATE ISSUED �. MAP/PARCEL NO. ADDRESS VILLAGE k,.e - OWNER r DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE -• ELECTRICAL: ROUGH FINAL i PLUMBING: ROUGH FINAL ' GAS:- -ROUGH FINAL ` FINAL BUILDING - D — •' t DATE CLOSED OUT ASSOCIATION PLAN NO.I _ t ' 0 Gl�rJ er Gc10✓z�CI�G' f (Dru GD Gv Gy- "Af G G G.4GL TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel bv6A Application# �'�CJ �a Ll Health Division Conservation Division P)Q &tL :NC-SW hu Permit# Tax Collector Date Issued ay 6Ez Treasurer Application Fee 60 a Planning Dept. Permit Fee .:1 . Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address (0 C e, Village Owner 9,11k5 S . 5�o�n� S o� Address 13 b r oa�C�' Telephone l 3 b ), — Permit Request f o v., 15 tC±S 0 �0 1C (o 1Iti3O,A C�r_ S 'CL&V o y) W Ln il` LILVI 1 e S CCU, . 2 C- 1 ` quare feet: 1 st floor: proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation O Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting docurri( ntation'P , C' N Dwelling Type: Single Family � Two Family ❑ Multi-Family(#units) tj,I w Q" a` > Age of Existing Structure Historic House: ❑Yes Cl No On Old King sHighway�1❑Yes- ❑No Basement Type:All ❑Crawl ❑Walkout ❑Other _ > r Basement Finished Area(sq.ft.) Base nt Clf: nishe rea(sq.ft) -'' M Number of Baths: Full:existing new existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas x0i,l ❑Electric ❑Other Central Air: ❑Yes �o Fireplaces: Existing � New Existing wood/coal stove: ❑Yes ❑No Detached garage:JVexisting ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes O No If yes,site p:Ian review# y,�s..� ,._6rxl/, _ Current Use Proposed Use P,✓ �it/�- :-o7v / BUILDER INFORMATION LX Name ,We 0�^' e� Telephone Number l Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE d F F r FOR OFFICIAL USE ONLY 4 PERMIT.NO. ~- DATE IS-SUED MAP/PARCEL NO.. ADDRESS VILLAGE t OWNER DATE OF INSPECTION: FOUNDATIONTp�D FRAME INSULATION i FIREPLACE r- ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ` FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i i The Commonwealth'ofMassachusetts Department oflndustrialAccidents Office of Investigations . 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 1 Please Print Legibly Name (Business/Organization/Individual): . 1 ` X5 S Address: le?) to ('. City/State/Zip:W S6YA&�e VAV� 0 a`6W Phone:#: 60�' 3 0 - 'j 9' +(j Are you an employer? Check the'appropriate boz: 'Type f project(required):. 1.❑ I am a employer with 4• ❑ I am a general contractor and I e * have hired the sub-contractors 6. New construction .'KO Ga employees (full and/or part-time). ' listed.on the'attached sheet. 7. 2/Remodelin ° 2.❑ I am a'sole proprietor or partner- g 'o) jo shipand have no employees These sub'contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' ro vrorkers comp.insurance comp.insurance.# 9. ❑Building addition P required.] 5. ❑ Vice are a corporation and its 10.❑Electrical repairs or additions 3.M I am a homeowner doing.a officers have exercised their.,all work 11.❑Plumbing repairs or additions myself. [No workers' comp. right'of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13:❑Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidairit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContnctors that cheek this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees: If the sub-contractors have employees,they must provide their workers'comp.policy number. Iam an employer that is providing workers'compensation insurance for my employees. Below is.thepolicy and job site information. Insurance Company Name: Policy#or Self ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORD=R and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Off_ ff ce of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and,correct, Signature: Date: Phone#: Official use only. Do not write.in this area, to be completed by city or town official �) Cit3'or Town: Pere- License# I((� iI Issuing Authority(circle one): I{ :1..Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a-deceased employer, or the ieceiVP.T or tmSee of an individual�partriership association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewat of a license or permit to'operate a business or to construct buildings in the commonwealth for any applicant who has not produced:acceptable evidence of compliance with the insurance coverage required:" Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract forthe performance of public work until-acceptable evidence-of compliance Kith the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contiactor(s)name(s), address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies.(LLC)or Limited Liability Partnerships(LLP)with no employees other.than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pemut.or.license is being requested,not the Department of Industrial Accidents., Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials. Please.be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact'you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy'information(if necessary)and unifier"Job Sile Address"the applicant should write"all-locations in (city or town)."A copy of the affidavit that has.been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questiol please do not hesitate to give us a call. The Department's address,telephone'.and fax number: The Commonwealth of Massachusetts Department of Industrial Accid=ts Office of Inyu-tigat ins 600'Washington Street Boston,ILIA 02111 Ter. #617-727-490.0 ext 406 ar 1-977-M- ASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/6a / E lvrrl1 v11Ja111a7L"LJPla+ Regulatory Services Thomas F.Geiler,Director an l ► Building Division Tom.Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.tow-A.banstable.ma.us Czce: 508-862-4038 Fax: 508-190-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW -SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction, alterations,renovation,repair,modernization, conversion, improvement;removal, demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units.or to Structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along Rzth other requirements. Type of Work: Estimated Cost 5.1 613 Address of Work:. w S UJ k Ba�V\S 0h0-()a 66 Owner's Name: Date of Application ISO I y 17 I hereby certify that: Registratign is not required for the following reason(s): []Work excluded by law []Job Under$1,000 ❑ uilding not owner-occupied [✓Owner pulling own permit Notice is bereby given that: OyMRS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c..142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Signature Registration No. OR Date Owner's Si attue Q wpfiles.fornwhom eaffi d xv Rev: 060606 pFIKE ram, Town of Barnstable Regulatory Services BARNSTABM Thomas F.Geiler,Director MASS. 1639. A � Building Division soy Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: o 0 pO 1. 1 r f,,(p ��/) /` (�- JOB LOCATION: C a-sC W cxv i�J YJ�'l f �I if O�p tj(J number ff T street ?/ village/ p (�' "HOMEOWNER": I�`t SS el k V o ksxr0 y1 � J l9 0 � ' D '—Y D 6 na e / home phone# work phone# CURRENT MAILING ADDRESS: I L,e- 0.\r E on w t 6aEks C tM il,4--oa city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of HomeoTr Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forns:homeexempt Application to ®rb ittg'� Jigbbw Regional JL@liotoric ;Biotrict Committee In-the Town of Barnstable CERTIFICATE OF APPROPRIATENESS D C JUL 0 n Application is hereby made, with four complete sets, for the issuance of a Certificate of A pro natenessU697Seatio 6 of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as de cri d- elew-and_no_planst, drawings,orphotographs accompanyingthis application for. ��/ 1-11-, ARNSTABLE 9 PP HISTO,I A E`.SEMIA.- iV CHECK CATEGORIES THAT APPLY: G p 1. Exterior building construction: ❑ New ❑ Addition ❑ Alteration Indicate type of building: ❑ House ❑ Garage ❑ Commercial ❑ Other 2. Exterior Painting: ❑ � � 3. Signs or Billboards: ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign 4. Structure: El Fence El Wall El Flagpole ❑ Other P,Q,1�s TYPE OR PRINT LEGIBLY: DATE g-I ADDRESS OF PROPOSED WORK I3b CeJ,6.V S+, &VwV ASSESSOR'S MAP NO. 3 �. OWNER I\WSSP/h ��0�� d� ASSESSOR'S LOT NO. a 0 l HOME ADDRESS C 3 6 l.l% � aVbl b v �j0 TELEPHONE NO.5 L-36o2".3n FULL NAMES AND ADDRESSES OF ABUTTING OWNERS, including those of adjacent property owners across any public street or way. (Attach additional sheet if necessary.) kut kA v o' w --I-a,,,,• Vk uvm10 ell V�s GV WV WV's b�e � ro.AGENT OR CONTRACTOR ELEPHONE ADDRESS DESCRIPTION OF PROPOSED WORK: Give particulars of work to be done, including materials to be used. Please include locations of proposed signs. t 1 (o f ' d ic- w" ,P-e v►n o-e,d Tv o m o Lti _ a-# "'t w �Q A w-L 60,� ��- it b � s,e f i� tN ��Ic�r w v1 e� -rV fl,e, 5 '� � VC Sys �. e(pV,,�a� X00 b , T w ,�c1 b 1 lac i +A_k� �,� aw c r �'n."'' C`'� � � (.�j l c�-$c,�- Signed � 2v-f�� Owne ontractor-Agent a F PeresN tee, ,A-v ke uN) a, S For Committee Use Only This Certificate is hereby Date Approved/fl ied , Committee Members' Signatu i Jla Town of Barnstable Old King's Highway Historic District Committee ll SPEC SHEET 0 II FOUNDATION^ 5ouno T"eg eV f 4 car` 4G -) SIDING TYPE COLOR CHIMNEY TYPE COLOR ROOF MATERIAL COLOR PITCH WINDOWS COLOR SIZE TRIM COLOR DOORS COLORS SHUTTERS COLORS GUTTERS COLORS • p�e�sw�. �-+�11 .,^�1,-e� �3�� ��1�( "_�� � �5� , 3v�sd- �\x �o'', p�d�y'X•�� �a;ls�Z�Xb� DECKS ���C �w�l�S t�rS MATERIALS GARAGE DOORS COLORS SKYLIGHTS SIZE COLORS U E C E JuL 0 3 200 SIGNS COLORS --TOWN OF BARNS T,*8 HISTC-1IG PRESER� 1 FENCE COLOR NOTES: Fill out completely, including measurements and materials/colors to be used. Four copies of thits form are required for submittal of an application, along with Four copies of the plot plan, landscape plan and elevation plans, when applicable. SPECSHT Revised 11/98 50" s� o a669- 5 0� � IDKC E- VE JUL 0 3 2007 --------------------------------- TOWN OF BARNSTABLE HISTO11 .IC PRESERVATION -iIo T c era l via s I�u �0. C �Tov- Tie- ax c�- Ems- co'"�47- �nc,�o� 3 of I r 2 J e-L..,� F: Yt: +Ism try,' �� � TH•rE _s 40 x ing D AC 2� 300 ,on chambers 7' U ie all around. JUL 0 3 2007 `1•� F h, EXISTING h TOWN OF BARNSTABL 'T LyQTORIC PR AA 4 — x 97 II I I I I x 964V O DIRT DRNE 99A8' 97.94' x ftw 9G7E' i a CaSIM LDE `rL� f' x SSW F ' 99.64 ED TO eE 00, 0000 B.M. ,y��' S l G� Cl F� o PROPOSED WELL 1- 58" — 76" ess than 15 minute soak period it Inch for design purposes o F & SOIL EVALUATION r do SOIL EVAL: OCTOBER 3. 2005 Y. G. HARRINGTON. R.S. i;r,d. ._ IALD DESMARAIS. R.S. HEALTH INSPECTOR . EXISnN OTT FRANK. MASS CAPE CONSTRUCTION #122 CEI Test Hole No. 2 Existing House " EVDOM SOILS ELEV 10' min. fromAT 0 ;, house to septic tank „.3. fU � � �. o�...,�.m� .b tOM1y! "a ''r� 5 HOLE u�wr awo cellar ► j DIM BOX BIN LOAIIl'MIO S'p p�' �8 or mwt be "1gppp��p for 500G�A{L. QV I �°�C�jAN c D— 01 R Z' P=4. I . 4 \AA-'nCI I (>1� A1 fn 1d ) �,p���c1 /)S • FTI s o � S � cos o 1 1 9 � � - Y, 9S, -- ,g09 i r ' �rh I �i Town of Barnstable *Permit# 95 -1 S— ®P ��S PE �1T Expires 6 mo hsfrom usugdate 2005 Thomas ulato Services Fee C �V OCT 0 bg rY F.Geiler,Director TOWN OF gARNS Building Division `�ji r ,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us - Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY i Not Valid without Red X-Press Imprint Vlap/parcel Number !3 l7 0 O Property Address b Ce.c1#.1J- V" ���S �� / 1 6 b Residential Value of Work JaSC0c) Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address N 0LV1 Cu R ASS d Contractor's Name V1 Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: am a sole proprietor I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) �Re-roof(stripping old shingles) All construction debris will be taken to ±4&A owlaq i/ilk coomekc►fal ❑Re-roof(not stripping. Going over existing layers of roof) 1 ❑' Re-sidej��� ❑ Replacement Windows. U-Value (maximum.44) \ *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 1 ne.t ommonweatrn of massacnusetts Department of Industrial Accidents Office.of Investigations ' 600 Washington Street Boston,MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): 1_�I Address: City/State/Zip: iJy— i� �s�-,�glL, Phone#: (�SO�r.� ,a 876 Are you an employer?Check the-appropriate box:. Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. El New construction employees(full and/or part-time).* have hired the sub-contractors 2.0 7 I am a sole proprietor or partner- listed on the attached sheet ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. 9, ❑ Big addition o workers' comp. insurance 5. ❑ We are a corporation and its . Electrical equired.] officers have exercised their 10 ❑. repairs or.additions 3. I am a homeowner doing all work right of exemption per MGL 1.1.❑ umbing repairs or additions myself. [No workers' comp. C. 152,§1(4),and we have no 12. Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.❑ Other.'. *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: `a t Homeowners.who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractws that check ibis box must attached an additional sheet showing the name of the sub-contractors and their workers'coup.policy information. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance.Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$.1,500;00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a.fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DiA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si ature:. SQL Date:.. / — .-Q Phone#: D - Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2..Building Department 3.City/Town Clerk 4..Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• I Information and Instructions - Massachusetts General hap Laws chapter 152 requires all employers to provide workers' compensation for their employees`.' { Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined association, Fozporation or other legal entity,or any two or more as _ .dn�.P: erslup;: of the foregoing.engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees.ant of t ant of t .er:the owner of a dwelling house having not more than three apartments and who resides therein,or.the occuphe dwelling house of another who employs Persons to do maintenance, construction or repair woik•on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the.commonwealth for any applicant who has not produced acceptable evidence-of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners; are not required to carry workers' compensation insurance. If an LLC or LLP does have this affidavit may submitted to the Department of Industrial employees,a policy is required. Be advised that Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below.. Self-insured companies-should-enter their.-. self-insurance license number on the appropriate line. City or Town Officials . Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the appl ict Please be sure to fill in the permt/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in L(city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that.a valid affidavit is-on file for:future permits.or licenses..Anew affidavit must be filled out.each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and.fax number: The Commonwealth of Massachusetts . Department of Industrial.Accidents Office of jnvestigaoons ,. .600 Washington Street . Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-.877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia Application:to: 96 Old Kings Highway Regionaf Historic District Committee in the.Town of Barnstable for a CERTIFICATION.OF EXEMPTION Application is hereby made, in triplicate,for the issuance of a certificate of exemption under Section 6 and 7 of Chapter 470, Acts and Resolves of Massachusetts, 1973, as amended for proposed work as described below and on plans, drawings, or photo- graphs accompanying this application. ; TYPE OR PRINT LEGIBLY �.� C �qv— sa-� DATE ADDRESS OF PROPOSED WORK - W, QOACAL" e, .M 4_02416R ASSESSORS MAP NO. 130 ®0 OWNER P4_&SSo ASSESSORS LOT NO. HOME ADDRESS ��d ®X l W�$� ��CL• MP, TEL. NO. 0:n)l 6.9g—aa�. AGENT OR CONTRACTOR �s ADDRESS TEL. NO. This application is for exemption of proposed exterior construction on.the ground that: ❑ (1) It will not be visible from any way or public place. ❑ (2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commission. (Check applicable box) PROPOSED WORK: Describe and furnish plan of proposed work, showing location on lot, and, if an addition is involved,show" ing location of existing building. 1 Q ewe o 3 7,6 S(n [.ej Q k&a1 ire`o tc,,C 6 SIGNED Space below line for Committee use. . Owner-Contractor-Agent Received by H.D.C. (� The Certificate is hereby Data �� v Time AFIJKU By Date Approved The categories of work entitled to exemption are listed on Disapproved the back of this form.